Authorization For Medical Treatment Form - Lake Ray Hubbard Pediatrics

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Authorization for Medical Treatment
Lake Ray Hubbard Pediatrics, PA
If your child needs medical, dental or hospital services, a parent must
how to reach you at all times. And when you know you will be hard to
give permission. It's the law. What about times when you cannot be
reach, you can give permission to other adults. They can then act for you
reached for permission? A child may be treated without parental
by permitting your child to be treated if unexpected care is needed.
consent when a physician determines a true emergency exists. That
means the doctor determines the child needs immediate medical care
This is a legal document. With it you may appoint relatives, friends,
and that an attempt to obtain parental consent would result in a delay
teachers clergy, neighbors - anyone who is over 18 years of age - to be
which would increase the risk to the child's life or health.
responsible for your children when you are away from them. It is
especially important to prepare this form for the occasions, when you know
Except in a true emergency, care may be ordinarily rendered to a
it will be hard to contact you.
child only with the consent of the parent or legal guardian.
Sometimes a child may need unexpected care which is not, however,
Fill out this form. give it to the adult(s) you have named to act on your
a true emergency. In such cases, making an effort to contact a parent
behalf. If your child needs unexpected medical treatment. the responsible
for permission can delay treatment and create unnecessary anxious
adult(s) should present this document to the appropriate person- physician.
moments for the child.
dentist or hospital representative.
You can prepare for unexpected care your children might need when
you are away from home. To do this, make sure babysitters know
AUTHORIZATION FOR MEDICAL TREATMENT OF MINORS
Name of Minor(s)
DOB
Allergies/ Special Conditions
I/ We, being the parent(s) or legal guardian(s) of te above named minor(s), do hereby appoint:
Name
Address
Phone #
To act in my/our behalf in authorizing unexpected medical, dental, surgical care and hospitalization for the above named minor(s) during the preiod of
my/our absence, from:
This document shall be presented to a physician, dentist or appropriate hospital representative at such time as unexpected medical, dental, surgical, care
or hospitalization my be required.
Signature of Parent / Guardian
Address
Signature of Parent / Guardian
Address
Signature of Witness
Address
Address
Signature of Witness
Hospitalization Coverage for above Named Minor(s)
Insurance Company or Government Program ID or Contact #
Family Physician:
Name:
Phone:
All articles and any forms, checklists, guidelines and materials are for generalized information only, and should not be reviewed or referred to as
primary legal sources nor construed as establishing medical standards of care for the purposes of litigation including expert testimony. They are
intended as resources to be selectively used and always adapted - with the advice of the organization's attorney - to meet state, local, individual
organizations and department needs or requirements. They are distributed with the understanding that neither Texas Medical Liability Trust nor
Texas Medical Insurance Company is engaged in rendering legal services.

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